Part B Insider (Multispecialty) Coding Alert

Plus: Document the specific reason for case cancellation.

The descriptor for modifier 53 (Discontinued procedure) is simple enough, but do you know what constitutes a situation when a physician stops a procedure “due to extenuating circumstances or those that threaten the well-being of the patient,” according to the CPT® explanation? Keep our experts’ advice in mind to rest assured you’re meeting the necessary criteria.

Build From a Basic Understanding

Modifier 53 describes an unexpected problem, beyond the physician’s or patient’s control, that necessitates ending the procedure. The physician doesn’t elect to discontinue the procedure so much as he is forced to do so because of unforeseen circumstances.

The key thing to remember for modifier 53 is that it is for services that are discontinued for very specific reasons. These might include:

• The patient develops a contraindication and the procedure must be discontinued for patient health reasons. Examples are respiratory distress (518.82), hypoxia (997.01), or irregular heart rhythm (427.9). The patient might also develop an issue related to the anesthesia.

• The physician (provider) cannot continue the procedure for some reason (e.g., surgeon cut his hand).

• The equipment is not working properly and the procedure must be cancelled (e.g., laser is not functioning correctly).

Back it up: You should have clear documentation for terminating the procedure and a supplemental diagnosis, such as a code from category V64.xx (Persons encountering health services for specific procedures, not carried out), if available, to better explain the claim.

Potential trap 1: You cannot submit modifier 53 when the patient elects to cancel the procedure or service. In fact, CMS states that modifier 53 “is not used to report the elective cancellation of a procedure prior to the patient’s anesthesia induction and/or surgical preparation in the operating suite.”

“Modifier 53 is not valid for elective cancellations prior to either anesthesia induction and/or surgical preparation in the operating suite or procedure room,” explains Judith Blaszczyk, RN, CPC, ACS-PM, medical compliance auditor at Auditing for Compliance and Education, Inc. in Overland Park, Kan.

Potential trap 2: From an anesthesia perspective, the surgery is cancelled but the anesthesia may not have been – especially if the case is cancelled after induction.

“Anesthesia does not reduce the amount of services they are providing,” explains Kelly Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fla. “If the case is cancelled prior to induction, a consultation or E/M code may be warranted if the surgery is not rescheduled within a reasonable time frame.”

Verify When the Case Stopped

Procedures might stop at any time when the anesthesiologist or surgeon sees some risk that could threaten the patient’s health if the case continues. Either physician can cancel the procedure at any one of three points, which means your coding depends on the timing.

Preoperative visit: Your anesthesiologist completes the standard preoperative visit but believes the patient is not a good elective surgical candidate for some reason (for example, because the patient has a fever and lung congestion). He discusses the situation with the surgeon, and the surgeon cancels the case.

If the rescheduled date is far enough in the future to merit another complete pre-op evaluation (usually at least two or three weeks later), you can bill the original exam. You might be able to report a consultation code (99241- 99245 for office/outpatient or 99251-99255 for inpatient) when the case is cancelled before your physician provides any anesthesia service – if the payer accepts consultation codes.

The pre-anesthesia or preoperative form is usually comprehensive enough to satisfy the E/M requirements. Other payers suggest reporting an E/M code, though, so check the applicable guidelines.

Your doctor’s second pre-op visit (when the case actually takes place) is included in the base value of the anesthesia service at the time of surgery. In the past, you might have reported the cancelled visit with an E/M code and modifier 53 but that’s no longer correct. Current CPT® guidelines state that you don’t use modifier 53 “to report the elective cancellation of a procedure prior to a patient’s anesthesia induction and/or surgical preparation in the operating suite.”

Before induction: The hospital staff takes Mrs. Smith into the operating room. Before the surgery begins, your anesthesiologist sees an arrhythmia when he begins monitoring her. Her surgeon cancels the case so she can be evaluated and rescheduled.

Check your payer guidelines before reporting the cancellation to be sure you submit the claim correctly. Also check the state-specific carrier guidelines, as there are quite a few.

After induction: Your anesthesiologist induces Mr. Jones but sees a sudden drop in blood pressure. He advises the surgeon that the case should not proceed. He reverses the anesthesia, and Mr. Jones transfers to the intensive care unit or other area for stabilization and further tests.

You have two coding options in this scenario. Some payers allow you to report the actual code in these situations (based on the planned procedure); others prefer 01999 (Unlisted anesthesia procedure[s]). Either way, you’ll also want to append modifier 53.

From an anesthesia standpoint, the preferable way is to report the actual anesthesia code since it has an associated base value. Code 01999 is reimbursed based on individual consideration but must be reported if required by the carrier. 

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